Provider Demographics
NPI:1275175622
Name:BUNNEY, MORIAHN (PA-C)
Entity Type:Individual
Prefix:
First Name:MORIAHN
Middle Name:
Last Name:BUNNEY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:MO
Other - Middle Name:
Other - Last Name:BUNNEY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:2901 POWDER BASIN AVE
Mailing Address - Street 2:
Mailing Address - City:GILLETTE
Mailing Address - State:WY
Mailing Address - Zip Code:82718-6406
Mailing Address - Country:US
Mailing Address - Phone:307-682-6222
Mailing Address - Fax:
Practice Address - Street 1:2901 POWDER BASIN AVE
Practice Address - Street 2:
Practice Address - City:GILLETTE
Practice Address - State:WY
Practice Address - Zip Code:82718-6406
Practice Address - Country:US
Practice Address - Phone:307-682-6222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-16
Last Update Date:2019-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1165639363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical